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Concept Paper
Significance of Introducing an Effective Multidisciplinary
Team
Konara Mudiyanselage Tikiri Bandara Gunathilake1* , Muditha Vidanapathirana2
1
Office of the Judicial Medical Officer, Base Hospital, Awissawella, Sri Lanka
2
Department of Forensic Medicine, Faculty of Medical Sciences, University of Sri
Jayewardenepura, Sri Lanka.
Introduction
When drug misusers are produced before forensic practitioners, the police expects opinions on intoxication, fitness
for an interview, drug searches, referral for rehabilitation etc. In Sri Lanka, according to “Drug-dependent persons
(Treatment and Rehabilitation) Act, No. 54 of 2007”, the forensic practitioners are expected to give their opinions
with scientific reasoning. Therefore, when giving opinions on drug abusers, forensic practitioners face many practical
problems.
Objectives
To evaluate the outcomes of medico-legal examinations of drug abusers presented to the Office of the Judicial Medical
Officer, Provincial General Hospital, Ratnapura in 2017 and to develop an effective multi-disciplinary program to
manage the same in Sri Lanka.
Background history
The objectives of the police were to obtain opinions on intoxication, addiction and refer to rehabilitation centres etc.
Twenty-three drug misusers were produced for medico-legal examinations. Two denied drug misuse. In 19, the
average time interval between arrest and producing was three days. In seven, there were no stigmata of abuse other
than tattoos. One cannabis misuser had a psychiatric illness. Following examination and psychiatrist referral, the
remaining 22 did not have evidence of acute intoxication or features of withdrawal syndrome. None of them was found
to be drug-dependent and the referral for rehabilitation was not indicated.
Conclusions
Similar to the cases of child abuse, it is necessary to develop a multi-disciplinary follow-up system. A ‘pre-arrest
referral scheme’ for drug misusers in the community and ‘post-arrest referral scheme’ when in custody. This can be
further strengthened by adding a scientific test. Then the forensic practitioners will be in a better position to give
opinions on drug dependency.
This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0
International License, which permits unrestricted use, distribution and reproduction in any medium
provided the original author and source are credited
Received: 17 April 2018 Accepted revised version: 01 May 2018 Published: 30 June 2018
Cite this article as: Gunathilake KMTB, Vidanapathirana M. Medico-legal management of drug abusers and
significance of introducing an effective multidisciplinary team. Medico-Legal Journal of Sri Lanka, 2018;6(1):22-26
DOI: http://dx.doi.org/10.4038/mljsl.v6i1.7368
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Medico-Legal Journal of Sri Lanka, 2018;6(1) Open Access
Introduction Objectives
Management of drug-related problems is a burden for To evaluate the outcomes of the medico-legal clinical
any country irrespective of rich or poor or developing examinations of drug abusers produced by the police
or developed.[1] In Sri Lanka, drug abuse is a serious to the Officer of the Judicial Medical Officer,
problem affecting young productive generations and Provincial General Hospital, Ratnapura, in the year
creating social and legal problems due to increased 2017 and to develop an effective multi-disciplinary
crimes rates and it costs millions of rupees.[2] In the program to manage the drug abusers.
United States of America, in 1999, it was 14 billion
dollars.[3] According to the US Surgeon Generals Background history
report on alcohol, drugs and health, 2015, the annual
economic impact from the misuse of prescription Twenty-three (n=23) suspected drug misusers were
drugs, illicit drugs or alcohol is $442 billion.[4] produced for medico-legal clinical examination. The
objectives of the police were to obtain opinions on
According to the 2004 executive summary of the intoxication, addiction and refer them to rehabilitation
United Nations office on drugs and crimes, there were centres etc. All were males. Most (n=20) were
about 45,000 regular users of heroin and about between 30-35 years of age. Two denied drug misuse.
600,000 users of cannabis in Sri Lanka. It was further In 19 cases, the average time interval between arrest
estimated that between 1–2 % of heroin users are and producing was 3 days. In seven (n=07), there were
intravenous drug users (IDUs).[5] In Sri Lanka, in no stigmata of drug abuse other than tattoos on arms,
2015, from January to June, 8570 persons were which on the other hand may not be associated with
arrested due to drug-related crimes. Of them, 1795 drug use at all. One cannabis misuser had evidence of
were heroin addicts, 5732 were married and 21% were psychiatric illness. Following examination and
between 30-34 years of age.[6] Further, when a married psychiatrist referral, the remaining suspects (n=22) did
person becomes a drug addict there is a high chance of not have any evidence of acute intoxication or features
increasing gender-based violence and other related of withdrawal syndrome. None of them was found to
social problems.[6] These show the gravity of the issue. be drug-dependent and the referral for rehabilitation
Addicted persons have multiple drug-related problems was not indicated.
other than intoxication. Further, they may have
multiple medical problems directly or indirectly Discussion
related to drug abuse. Forensic practitioners owe a
duty of care to treat the acute problems and must act Substance misuse can lead to medical, social and legal
in good faith for the best interest of the patient. problems. Not only the victim but also the society may
Moreover, they have legal and social obligations on be victimized due to drug abuse. Therefore, the use of
public interest. However, they should act within the substances would constitute a public health and social
legal framework and they cannot deviate from the problem.[9] According to the ICD-10 classification, the
standard practice even when managing drug addicts. If dependence syndrome is defined as being a cluster of
there were legal provisions or protocols, those could physiological, behavioural, and cognitive phenomena
have been used as guidelines and the forensic in which the use of a substance or a class of substances
pathologists can safeguard themselves if they act takes on a much higher priority for a given individual
accordingly and responsibly. than other behaviours that once had greater value.
Therefore, “The Drug-dependent persons (Treatment
When the suspects of drug misusers are produced and Rehabilitation) Act, No. 54 of 2007” expects the
before forensic practitioners, the police may expect forensic practitioners to identify the drug-dependent
opinions on intoxication, fitness for an interview, drug and to refer to a rehabilitation programme.
searches (body packers, stuffers), referral for
rehabilitation etc.[7] In Sri Lanka, according to “Drug- There is a common belief among the legal authorities
dependent persons (Treatment and Rehabilitation) that the misuse and addiction are the same. The
Act, No. 54 of 2007”, the forensic practitioners are medico-legal examination may be complicated if the
expected give their opinions with scientific misuser is addicted to a drug. The seriousness of the
reasoning.[8] Due to such expectations of the Act, when addiction depends on the type of drug, state of
giving opinions on suspects of drug abuse, there are intoxication and degree of addiction. Further, in
many practical problems for the forensic practitioners addicts, the self and social harm are more.[9]
such as whether the suspects are dependents or not etc.
Once a drug misuser is produced before a forensic
practitioner, a thorough clinical examination must be
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performed. Some of the general findings in substance (vi) Important social, occupational or recreational
misuse are neglect, poor nutritional state, dental caries, activities are given up or reduced because of
the external stigma of intravenous drug abuse, bizarre substance use.
tattoos etc.[10] In this case study, seven (n=07) had
tattoos but they were well-made ones rather than the 3. Some features can be identified from victim,
bizarre types expected in intravenous drug addicts. family and the treating physicians.
(vii) Continue the substance abuse despite the
In intoxication, the misuser’s central nervous system
knowledge of causing physical and
is affected by the abused drug. Clinical features
psychological damage.
depend on the type of drug used. Here, especially the
level of consciousness, cognition, perception and According to the above criteria, it is understood that
judgment or behaviour etc are affected. [11] Medico- for the diagnosis of drug addiction, most important
legal examination of impairment assessment must be factors are the history taken from the patient, family
done to find out evidence of acute intoxication. members and the treating physicians and the features
Only one person (n=01) who was taking cannabis for should persist for more than one year. Further,
a long time had features of a psychiatric illness. according to the Act No. 54/2007, the forensic
However, he did not have any clinical features of practitioners should give opinions with reasons and
addiction or withdrawal. Other cases (n=19) were based on the facts. However, this could never be able
produced before the forensic practitioner three days to be achieved with present examination system,
after the arrest and following medico-legal where the forensics practitioner meets only the patient
examination with referral to a psychiatrist, had no which is also for too short a period.
clinical features of acute intoxication or dependency.
Withdrawal features of opioid addiction are severe in Further, the suspects or even their relatives may not
48-72 hours and then gradually disappear.[9] divulge reliable information. If the suspect is addicted,
he will almost never consider rehabilitation.
According to the Act No. 54/2007, when considering According to the above-mentioned definition of drug
rehabilitation, most important factor is whether the addiction, it is not possible for a medical professional,
person is a drug-dependent or not. Acute drug judicial medical officer or psychiatrist to decide
intoxication and drug addiction are completely whether the victim is a drug addict without a reliable
different entities. According to ICD -10 classification, history, long-term observation or monitoring of them
to diagnose drug dependency, 3 or more of following because they get only a short contact time with drug
7 features should persist for more than one year misusers. Therefore, following examination and
period.[12] psychiatrist referral of above 23 suspects, all did not
1. Some features can be identified by examination of have dependent features. This highlights the value of
the patient alone. community and custody based close monitoring
(i) Presence of tolerance, a need for an increased system to identify and manage the drug-dependents.
amount to achieve the desired effect or However, in Sri Lanka, in cases of child abuse, there
diminished effect with the same amount of is a special system to monitor the children and their
drug. families by the probation officers. Similarly, there
(ii) Persistent desire and unsuccessful efforts to should be a system to monitor the drug-dependents
cut down or control substance use. within their communities and custodies to facilitate
and design their future medical management or
2. Some features could be identified by examining rehabilitation.
the victim and interviewing the family.
In the United Kingdom, there is a program called ‘drug
(iii) Taking substance in a larger amount for a
referral or arrested referral scheme’. It is a partnership
longer duration.
initiative set up to encourage substance misusers
(iv) The appearance of clinical features of brought into contact with the police services to
withdrawal syndrome or taking the same or participate voluntarily in confidential help design to
closely related substance to avoid withdrawal address their problems related to substance misuse.
symptoms. There are two approaches in ‘arrested referral
(v) A great deal of time is spent on activities scheme’. (1) In information model, the police offer
necessary to obtain, use, or recover from its information in the form of a leaflet about drug and
effects. other relevant services to those they have arrested.
However, the take-up rate of this model has been
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found to be low. (2) The proactive model involves be residential rehabilitation interventions for those
‘drug workers’ working in close cooperation with the with severe co-morbid mental and/or physical health
police, often with the direct access to prisoners in problems.
custody. They may approach detainees in the police
station themselves, providing an assessment either on- As indicated above, when the withdrawal syndrome is
site or at a subsequent meeting. Here, information concerned, the medico-legal examination alone is not
about drug services and encouragement to see advice much useful. Moreover, the features of withdrawal
is always provided by the drug workers.[11] syndrome may have been disappeared due to delayed
In Sri Lanka, we do not have such follow-up or presentation. Further, the best proof of long-term drug
monitoring system. We can adopt this system and addiction is the hair analysis for drugs.[11]. By
appoint such ‘drug officers’ to develop a close rapport including such a test to our routine medico-legal
with drug misusers and their families. Further, the examination, the forensic pathologist would be able to
forensic practitioners can obtain necessary details obtain scientific facts related to the sequence of drug
from such officers to decide on the state of drug usage and test the reliability of the history given by the
addiction of the suspects for legal purposes. suspects as well.
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